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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 57 1 9—Aga zzq A W E City S'77 - Lot Size'40421-1' PM Phone Contractor 5 Owner's Name Address Conlractos DAddress License No. ?erg Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _ �SYSTEM..REP-AIRW❑...1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I _ SEWER LINES [ DISPOSAL. FLD. PROP. LINE r FOUNDATION ' 'AGRICULTURE WELL l „OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM_ARU,`�_CONSTR_UCTION SPECIFICATIONS .i ❑ Industrial ❑ Open Bottom`. ❑ Manteca Dia. of Well Excavation,— � � Dia.-of Well Casing ❑ Domestic/Private ❑ Gravel Pack l ❑ Tracy Type of Casing J ..- Specifications - ❑ Public ❑ Other 171 Delta + Depth of Grout-Seal I z Type of Grout I I Irrigation --Approx. Depth 1.1 Eastern!.: ,Surface Seal_Installed ty Repair Work Done 1-1Typeof Pump _ H.P. ' .fry state Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501% % / € Depth j Fille,,Material (Below 5Q +,`- TYPE OF SEPTIC WORK: NEW INSTALLATION I I—REPAIR4ADDITIOT-4 DESTRUCTION l I (No septic system permitted if public.sewer is ,, { f .r+fy 1 available within 200 feet) Installation will serve: Residence 'Commercial "Other s t Ai�p `" x '► "�y, j 77 4 Number of living units: l `Number:of'bedrooms - 3 Character of soil to a depth of 3'teet: t &i --I t �- ° Water table depth SEPTIC TANK ❑ Type/Mfg r " ' t ' -Capacity f No. Compartments PKG. TREATMENT PLT. ❑ - �---.I j Method of Disposal ev Distance to nearest: Well Found`aiibn""—"t Property.Line _ T LEACHING LINE ❑ No. & Length of Ines v��=�1l. `" ' 'Total length/size °FILTER BED ❑ Distance to nearest: + Well Foundation. Property Line f SEEPAGE PITS Depth /f3 l Size "I Number SUMPS Distance to nearest: l Well A41A oundation f O � j Property Line �Q k-FO DISPOSAL PONDS ❑ t -, -_ I �t ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di1trict. t. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become sribjecuo workman's-compensation Jaws-of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion.taws of California." 3 The applicant must call for all required in5pe tions. Complete drawing on revise;side. t Signed X Ttler: Date: _ ra =,a OR �pARTMENT USE ONLY aL I F `�,a� Db Area " Application Accepted by date Pit or Grout Inspection by t Date 1 t Final Inspection by _ Date _ " n n tAdditional Comments: b I ❑ Stk 466-6781 ❑ Lod' 369-3621 ❑`Manteca 823.7104 ❑ Tracy 835-6385 ik., ray +`Sr C P-�r r crypta Applicant- Return all copies to: Environmental Health Permit/.Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # FEE INFO AMOUNT DUE �AMOUNT REMITTED CASH RECEIVED BY �/7 DATE fJ PERMI/TjnNO. / �t IIJ fl +.EH 43-24 1REV.t/H 51 EH 14-26